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Inside this issue: Bronchiectasis.

Adult Patients with Bronchiectasis. A first look at the US Bronchiectasis Research Registry. 2

Research priorities in bronchiectasis: a consensus statement from the EMBARC Clinical Research Col-laboration.

3

Aetiology of bronchiectasis in adults: A systematic literature review. 4

Multi-dimensional severity assessment in bronchiectasis: an analysis of seven European cohorts. 4

Comorbidities and the risk of mortality in patients with bronchiectasis: an international cohort study. 5

Bronchiectasis severity is an independent risk factor for vascular disease in a bronchiectasis cohort. 6

A randomised controlled trial of atorvastatin in patients with bronchiectasis infected with Pseudomo-nas aerigunosa. A proof of concept study.

7

Bronchoarterial ratio in non-smoking adults: implications for bronchial dilation definition. 8

Pseudomonas aeruginosa adaption and diversification in the non-cystic fibrosis bronchiectasis lung. 9

FUT2 Genotype Influences lung function, exacerbation frequency and airway microbiota in non-CF bronchiectasis.

10

The development and validation of the Bronchiectasis Health Questionnaire (BHQ). 11

Pulmonary exacerbation in adults with bronchiectasis: a consensus definition for clinical research. 11

The BRICS (Bronchiectasis Radiologically Indexed CT Score). A multicentre study score for use in idio-pathic and post-infective bronchiectasis.

12

APSR EDUCATION PUBLICATION

Newsletter Date: July 2018 Volume 10 Issue 7

APSR RESPIRATORY UPDATES

Articles selected and commented on by: Professor John Kolbe. Department of Medicine, Faculty of Medi-cal and Health Sciences, University of Auckland, Auckland City Hospital, Auckland, New Zealand

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That this is the second APSR Respiratory Update solely on the topic of bronchiectasis, reflects

the fact that this condition is, in the words of Professor Paul Torzillo, “shaking off its orphan

status” (Lancet Respiratory Medicine 2016; 4:927-928). This enhanced status is further re-

flected in the continued expansion of publications on the condition providing an increasingly

secure base for management, and in the early publications based on databases established

in the US and Europe. Pleasingly the name “bronchiectasis” has been reclaimed and the the

term “non-CF bronchiectasis” is being used much less frequently.

INTRODUCTION by Professor John Kolbe.

Authors: Aksomit T R et al

Reference: Chest 2017; 151: 982-992

URL:https://doi.org/10.1016/j.chest.2016.10.055

This is the first report arising from the US Bronchiectasis Research Registry, based on 13

participating centres and the enrolment of 1826 patients between 2008 and 2014. Patients

were predominantly elderly (mean age of 64 years), white (79%), female (79%), non smok-

ers (60%) with non-tuberculous mycobacterial infection (NTM) (63%) – with mostly MAIC

but about 20% were M. abcessus/chelonae. These are interesting demographic data which

seemingly fit the profile of those with the so-called “Lady Windermere’s Syndrome”. Howev-

er they may not be representative of the overall bronchiectasis population and it was

acknowledged that the cohort was enrolled from tertiary institutions with an interest in NTM.

The right middle lobe was the most frequently involved lobe (69%) but the more widespread

nature of the disease was reflected in the fact that only 11% had single lobe involvement.

Despite being the mainstay of management with proven benefit in terms of quality of life,

sputum volume and exercise capacity, only 56% were using “non-pharmacologic measures

to improve bronchial hygiene” with most using a Flutter device or PEP valve.

Another publication entitled “ Pharmacotherapy for non -cystic fibrosis bronchiecta-

sis” (Chest 2017; 152(6): 1120 – 1127; https://doi.org/10.1016/j.chest.2017.04.167) analysed

data from this registry (but now entitled “Bronchiectasis and NTM Research Registry”) and

from survey responders from a non-profit NTM patient advocacy organisation. The results

are noteworthy for the high rate of use of inhaled corticosteroids – 36% in those with NTM

and 42% in those without. This is despite the Cochrane Systematic Review on the subject

concluding that there is no convincing evidence of benefit from the use of inhaled cortico-

Adult Patients with Bronchiectasis. A first look at the US Bronchiectasis Research Registry.

https://doi.org/10.1016/j.chest.2016.10.055




steroids (ICS) in this condition, and that in chronic airways disease the use of ICS seem-

ingly increases the risk of NTM infection.

While the establishment of the US registry is a tremendous step forward, highlighting the

condition and advocating on behalf of patients, the inclusion of such a selective population

has the potential to distort our understanding of this condition. The challenge is now to ex-

pand the registry, to recruit from a wider range of centres, to be more geographically repre-

sentative, and to include ethnic minorities – and thus be more representative of the overall

bronchiectasis population and produce data that is more generalizable.

Author: Aliberti et al

Reference: European Respiratory Journal 2016; 48: 632 – 647

URL: http://erj.ersjournals.com/content/48/3/632.long

Further demonstrating the renewed interest in bronchiectasis, the European Multicentre

Bronchiectasis Audit and Research Collaboration (EMBARC) has been established under

the auspices of the European Respiratory Society, “to promote high quality research in

bronchiectasis”. This publication outlines the 55(!) key research priorities in this area, es-

tablished by consensus by European bronchiectasis experts, patients and their families and

resulting in 22 summary recommendations. These recommendations range from the estab-

lishment of DNA biobanks to enable study of genetic susceptibility, through observational

studies of large cohorts to better understand the natural history of the condition, to a num-

ber of randomised controlled trials of management strategies. This exercise to define key

research priorities is an ambitious undertaking that will serve to focus much needed re-

search in forthcoming years. One of the strengths of this endeavour is that it brought to-

gether the perspectives of “experts” and patients to produce a shared vision of research pri-

orities.

The European Respiratory Society has also published “Guidelines for the Management of

Adult Bronchiectasis”. (European Respiratory Journal 2017; 50:1-22). The format of this

document, developed by a multidisciplinary group, is to comprehensively address nine, clini-

cally highly relevant questions, providing recommendations, evidence, justification and com-

mentary on each of the specific issues. As well as being highly informative, this article pro-

vides management recommendations that could be used for audit, benchmarking and quali-

ty improvement. However, relevant to the EMBARC research priorities, was the acknowl-

edged low quality of evidence for a number of the recommendations.

Research priorities in bronchiectasis: a consensus statement from the EMBARC Clinical Research Collaboration.

http://erj.ersjournals.com/content/48/3/632.long



Author: Gao Y-H, et al

Reference: Respirology 2016; 21: 1376-1383

URL: https://onlinelibrary.wiley.com/doi/full/10.1111/resp.12832

This systematic literature review identified 56 studies of a total of 8608 adults with bronchi-

ectasis. Reflecting the lack of a consistent definition for “idiopathic bronchiectasis” but also

possibly regional differences and referral bias, the crude prevalence for identified aetiolo-

gies ranged from 18 to 95%. Overall an underlying cause could not be identified in about

half (44.8%). Of the “known” aetiologies, post infection was the most frequent (29.9%), of

which post-tuberculosis was most common. Identification of an etiology that led to a change

in management occurred in only 18%.

However there are recognised specific aetiologies/associations of bronchiectasis and some

of these have recently been reviewed; bronchiectasis-rheumatoid overlap syndrome ( Chest

2017; 151(6): 1247 – 54), the yellow-nail syndrome (Respirology 2017; 22: 10177) and pri-

mary ciliary dyskinesia (Expert Review of Respiratory Medicine 2017; 11: 779 – 90).

Aetiology of bronchiectasis in adults: A systematic literature review.

Multi-dimensional severity assessment in bronchiectasis: an analysis of

seven European cohorts.

Authors: McDonnell MJ et al

Reference: Thorax 2016:71:1110-1118

URL: https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/27516225/

In a previous APSR Respiratory Update, the two composite, disease-specific, clinical predic-

tion tools (the Bronchiectasis Severity Index (BSI) and FACED score) were reviewed. A re-

cently published single centre cohort analysis extended these findings by demonstrating that

both scores were able to predict 15-year mortality, but with the FACED score showing slightly

superior predictive power (Eur Respir J 2016; 47: 482-9).

This paper describes the head-to-head comparison of the predictive utility of these two instru-

ments in a large, combined European cohort (n=1612). As there is a considerable commonali-

ty in the factors included in these indices, it is not surprising that both scores had a good dis-

criminatory predictive value for mortality. However the BSI demonstrated a higher sensitivity

(65% vs 28%) but lower specificity (70 vs 93%) compared with the FACED score. The BSI

https://onlinelibrary.wiley.com/doi/full/10.1111/resp.12832

https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/27516225/



Comorbidities and the risk of mortality in patients with bronchiectasis: an

international cohort study.

Author: McDonnell MJ et al

Reference: Lancet Respiratory Medicine 2016; 4: 969 – 79

URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5369638/

The Bronchiectasis Severity Index (BSI) and the FACED score were both developed and vali-

dated in large cohorts, to predict mortality and morbidity in bronchiectasis. Understandably

these indices focussed on clinical, physiological, radiologic and microbiological features of bron-

chiectasis. However, bronchiectasis patients frequently have comorbidities that may be

“causative, synergistic or coincidental ….”. These comorbidities may contribute to symptoms,

functional impairment, morbidity, including hospitalisations, and mortality in patients with bron-

chiectasis.

In an observational cohort analysis of 986 bronchiectasis patients in four European centres,

comorbidities were defined and used to develop the Bronchiectasis Aetiology Comorbidity Index

(BACI). The median number of comorbidities per patient was four. Thirteen comorbidities

which independently predicted mortality were integrated into the BACI. The BACI predicted five

year mortality, hospitalisations, exacerbations and health-related quality of life, across all BSI

risk strata. The hazard ratio (HR) for death conferred by a one point increase in the BACI was

1. 18 (95%, 1.14 – 1.23); individual comorbidities attracted a score which ranged from 12

(metastatic malignancy) to 2 (peripheral vascular disease and ischaemic heart disease). COPD,

inflammatory bowel disease, connective tissue disease and asthma were also associated with a

performed more consistently across all degrees of severity and was superior to FACED in pre-

dicting other clinically useful outcomes including hospital admissions, exacerbations, quality of

life, respiratory symptoms, exercise capacity and lung function decline. This is not surprising

as the FACED was developed to specifically predict mortality while the BSI was developed to

predict mortality and other outcomes. While the BSI may be more useful to stratify patients on

the basis of risk of future exacerbations, it needs to be borne in mind that the BSI is more

complex than FACED.

In practical terms, the BSI may enable the identification of “high risk” patients in terms of cur-

rent symptom burden or likely future morbidity for whom more intensive treatment would be

indicated, and “low risk” patients who may require less intensive therapy and non-specialist

follow-up.

These instruments have only been evaluated in European cohorts and studies validating

these instruments in the Asia-Pacific populations would seem to be required.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5369638/



higher risk of mortality. Even when a model was developed excluding conditions considered to

be aetiologically significant, the HR was very similar (1.17). The BACI was validated in an in-

dependent cohort of 113 patients. However a prediction model incorporating both BSI and

BACI was superior to either model alone for predicting five year mortality.

In summary, comorbidities are common in bronchiectasis, may be independent risk factors for

morbidity and mortality and may contribute to the systemic inflammation seen in this condition.

An online calculator for BACI is available at http://www.bronchiectasisseverity.com. At the very

least this publication reminds us of the importance of identifying, assessing and managing

comorbidities as part of the overall management of bronchiectasis.

Bronchiectasis severity is an independent risk factor for vascular disease in a bronchiectasis cohort.

Author: Evans IES et al

Reference: Chest 2017; 151: 383 – 8.

URL: https://doi.org/10.1016/j.chest.2016.09.022

Bronchiectasis is associated with systemic inflammation. A recent study, based on a retro-

spective database showed that bronchiectasis severity as determined by the BSI, was inde-

pendently associated with the development of vascular disease (ischaemic heart disease, cer-

ebrovascular disease, peripheral vascular disease and atrial fibrillation) after the diagnosis of

bronchiectasis. Bronchiectasis severity as determined by the BSI was independently associat-

ed with the development of vascular disease.

Further, a population-based study of almost four million persons demonstrated that pre-

existing diagnoses of coronary heart disease (CHD) and stroke were higher in persons with

bronchiectasis than those without bronchiectasis, after adjustment for other risk factors includ-

ing age, sex, smoking status and other risk factors for cardiovascular disease (Thorax 2017;

72:161 – 6). “In absolute terms our findings suggest that if a cohort of 100 people with bron-

chiectasis were followed up for five years, they would have three CHD events and five strokes

whereas 100 people without bronchiectasis would have one CHD event and one stroke.”

Thus there is the possibility that the pro-inflammatory state of bronchiectasis may have conse-

quences in terms of vascular diseases. This has relevance in terms of the influence of co-

morbidities on health care utilisation and mortality and on potential therapeutic interventions,

needs further consideration ( see next).

http://www.bronchiectasisseverity.com




Author: Bedi P et al

Reference: Chest 2017; 152:368 – 78


Bronchiectasis is associated with system inflammation and statin drugs have anti -

inflammatory (as well as other) properties. An earlier study by the same group from Edin-

burgh demonstrated that atorvastatin reduced cough, enhanced neutrophil apoptosis and

reduced CXCL8 (also called IL8) in patients with moderately severe bronchiectasis without

chronic infection with Pseudomonas aerigunosa (PA). (Lancet Respir Med 2014: 2: 455 -63.)

This double-blind, cross-over, randomised trial of 32 patients with more severe bronchiecta-

sis and chronic infection with PA, demonstrated that three month treatment with the statin

atorvastatin did not improve the primary outcome of cough (as assessed by Leicester

Cough Questionnaire) but did improve quality of life ( assessed by St George’s Respiratory

Questionnaire ) and reduced levels of a number of inflammatory cytokines including CXCL8,

tumour necrosis factor and intercellular adhesion molecule 1.

To determine whether statins have any role in the management of bronchiectasis will re-

quire a much longer study with important patient centred outcomes.

A randomised controlled trial of atorvastatin in patients with

bronchiectasis infected with Pseudomonas aerigunosa. A proof of concept study.

Coming soon in Respirology: “Paediatric and Adult Bronchiectasis” an invited review se-

ries co-edited by Adam Hill and Anne Chang.

Publication starts end of 2018.

Sign up on the Journal’s page to get content alert:

https://onlinelibrary.wiley.com/journal/14401843


https://onlinelibrary.wiley.com/journal/14401843



Authors: Dias AA et al

Reference: Respirology 2017; 22: 108-113

URL: https://onlinelibrary.wiley.com/doi/full/10.1111/resp.12875

The defining radiologic feature of bronchiectasis is that of “airway dilation” based on the ra-

tio of the diameter of the bronchial lumen (B) and the adjacent pulmonary artery (A). A BA

ratio of >1 is the usual threshold for the radiologic diagnosis of bronchiectasis in adults.

The usual assumption is that an increased BA ratio is due to an increased airway lumen, but

could also be due to reduced artery calibre.

This study of the inspiratory CT scans of 106 never smokers, controls in the COPD Gene

study, mean age 62 years and 70% female, examined two bronchial paths; the right upper

lobe apical bronchus (RB1) and the right lower lobe posterior basal bronchus (RB10), cho-

sen because the airway branches of these segments are usually orthogonal to the axial

plane. The bronchial lumen and artery diameters were measured manually at points along

the path.

Overall the BA ratio was 0.79±0.16. In the RB1, but not the RB10 path, the BA ratio de-

creased in peripheral airway generations. The BA ratio was >1 in 8.5% of these normal

subjects. In those with BA>1, the artery diameter was smaller but bronchial lumen was not

larger than those with a BA ratio <1. In other words, the increased BA ratio is a broncho-

vascular process rather than solely a bronchial abnormality and in non-smokers a BA ratio

> 1 is driven by small arteries rather than luminal diameter. In multivariate analysis, BA

ratio was significantly associated with FEV1 and bronchial lumen size was more strongly

correlated with FEV1 than pulmonary artery diameter. These findings are consistent with

the concept of dysanapsis : that the bronchial tree and lung parenchyma may develop rela-

tively independently of each other. However these findings have important implications for

the diagnosis of bronchiectasis; clinically and epidemiologically.

All clinicians will be familiar with the unexpected radiologic reporting of mild thin walled

bronchiectasis, usually in the basal segments of the lower lobes in elderly patients who do

not have the clinical phenotype of bronchiectasis. Radiologic evidence of bronchiectasis

has been reported in up to a half of patients with severe COPD, and also in patients with

chronic severe asthma. In a study of the CT scans of 21 smokers with radiologic evidence

of bronchiectasis and 21 non-smoking controls, the BA ratios were higher in smokers with

mild bronchiectasis (as expected) but the increase was due to reduced calibre of the pulmo-

nary artery and not due to an increase in airway lumen size. Those with an increased BA

ratio had evidence of more severe airflow obstruction (Chest 2017; 151: 1255-62). Thus

Bronchoarterial ratio in non-smoking adults: implications for bronchial dilation definition.

https://onlinelibrary.wiley.com/doi/full/10.1111/resp.12875



smoking related increases in the BA ratio seem to be due to reductions in vascular calibre

rather than bronchial dilatation – termed “mistaken identity” in the accompanying editorial.

There would seem to be the need to review the use of artery diameter as a reference to de-

termine bronchial dilatation. The diagnosis of bronchiectasis is a clinical one and clinicians

need to interpret CT scans showing a BA ratio >1 in association with the patient’s clinical

features. Radiologic bronchiectasis may be common, but clinically significant bronchiectasis

may be much less common, in COPD .

Authors: Hilliam et al

Reference: European Respiratory Journal 2017; 49: 1602108.

URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898933/

In cystic fibrosis, there is evidence of the coexistence of multiple divergent lineages of

Pseudomonas aerigunosa (PA), and a number of transmissible strains of PA have been

identified. Whether the same applies to bronchiectasis is unclear.

This study of whole genome sequencing of 189 PA isolates from 93 patients with bronchiec-

tasis from 16 centres in England and Wales demonstrated that the distribution of the PA iso-

lates from bronchiectasis patients were representative of the wider PA population. There

was evidence of multi-lineage infections, and some sharing of PA with the same clonal line-

age within the same clinic suggesting common source acquisition or cross-infection. A larg-

er longitudinal study will be needed to determine if there is person to person transmission of

PA in the bronchiectasis patient community.

As in CF, there was evidence of adaption of PA to the lung environment by the accumula-

tion of loss of function mutations, leading to changes in phenotype, including different

modes of iron acquisition, changes in twitching motility and variations in biofilm -associated

polysaccharides.

Pseudomonas aeruginosa adaption and diversification in the non-cystic fibrosis bronchiectasis lung.

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898933/

https://onlinelibrary.wiley.com/toc/14401843/2018/23/7




Author: Taylor SC et al

Reference: Thorax 2017; 72: 304 – 310

URL: http://dx.doi.org/10.1136/thoraxjnl-2016-208775

Disease progression in bronchiectasis is variable and difficult to predict. One factor influ-

encing this progression is the airway microbiota; those with chronic Pseudomonas aeriguno-

sa (PA) infection having faster decline in lung function, more symptoms, worse quality of

life, more frequent pulmonary exacerbations and greater antibiotic requirements. Microbes

use glycans on the respiratory mucosal surface to adhere. Thus variability of the expres-

sion of these glycans may affect the susceptibility to infection by certain microbes and sub-

sequently the airway microbiome composition. The FUT2 gene encodes fucosyltranferases

which act to attach fucose to disaccharide precursors and hence control the expression of

ABO antigens on the epithelial mucin glycans. Homozygous loss of function mutations in the

FUT2 (secretor) gene results in the inability to express a number of glycans on the mucosal

surface.

Australian investigators studied the secretor genotype (the effect of loss of function muta-

tions of the FUT2 gene, both heterozygous and homozygous) on disease severity in 112

adults with bronchiectasis. FUT2 genotype was associated with disease progress; homozy-

gous secretors had lower lung function, greater number of exacerbations and a higher rate

of PA infection than homozygous non-secretors. Patients with a heterozygous genotype

demonstrated an intermediate phenotype. The authors speculated that the effect of secre-

tor status may be through susceptibility to respiratory viral infection. There is no direct link

between secretor status and PA infection.

Thus secretory genotype is a factor influencing type of chronic microbiological infection and

disease severity and progression in bronchiectasis. Bronchiectasis has a complex and in-

completely understood aetiology, but this may represent an early step towards the use of

precision medicine for a more effective approach to patient management in this condition.

FUT2 Genotype Influences lung function, exacerbation frequency and airway microbiota in non-CF bronchiectasis.

New in Respirology: Visual abstracts Visual abstract are gaining momentum in science publishing and prove valuable tools in the promotion and sharing of research findings online.

View our latest issue for featured visual abstracts.




Authors: Spinou A et al

Reference: European Respiratory Journal 2017; 49:


The authors of the editorial accompanying this article emphasise that there are three differ-

ent dimensions of any disease; severity, activity, and impact, and that the last of these is

usually evaluated by quality of life questionnaires. In a previous APSR Respiratory Update,

the report of the first disease -specific quality of life questionnaire for bronchiectasis (Quality

of Life – Bronchiectasis (QoL-B)) was reviewed.

This paper reports on the development and validation of another disease-specific quality of

life questionnaire – the Bronchiectasis Health Questionnaire (BHQ). This BHQ is simpler; it

has 10 items in one domain, compared with the 37 items and eight domains of the Qol-B.

The BHQ provides a single overall health status score which was shown to correlate with

numbers of exacerbations and hospitalisations, radiologic severity and bacterial colonisa-

tion. The Questionnaire has been translated into a number of languages including Japa-

nese and Mandarin and has been tested in a single center in China. However the minimally

clinically significant difference has not yet been determined, nor has the instrument’s re-

sponsiveness to interventions. While the BHQ meets the criteria for a good quality instru-

ment in terms of internal consistency, validity (most items reflect a good quality clinical his-

tory) and repeatability, it does not quantify health status in the psychological, activity and

social domains. Thus while the BHQ has the great advantage of brevity and simplicity, the

QoL-B has advantages if a more in-depth analysis of health status is required, particularly in

certain specific domains.

Authors: Hill AT et al

Reference: Eur Respir J 2017; 49: 1700051.


This consensus definition of bronchiectasis was “unanimously approved” by a multinational,

broad-based group of experts following a systematic review of the literature, a Delphi pro-

cess and a round table discussion. An exacerbation for the purposes of clinical research re-

quires at least 3 of 6 symptoms for 48 hrs and a clinician determining that a change in treat-

Pulmonary exacerbation in adults with bronchiectasis: a consensus definition for clinical research.

The development and validation of the Bronchiectasis Health Questionnaire (BHQ).





ment is indicated. Thus the definition includes 3 features - the development of symptoms,

duration of symptoms and a management change. While there are no surprises in the defi-

nition, the development of such an agreed definition of an oft-used primary outcome is an

important step forward for standardisation of clinical research in this condition.

Authors: Bedi P et al

Reference: Chest 2018; 153: 1177-1186


This paper describes the development of a simplified radiologic score (BRICS) in 184 pa-

tients. Patients who were current smokers or had a >5 pack year smoking history were ex-

cluded. The score was based on a multivariable analysis of components of the Bhalla

score (Radiology 1991; 179: 783-788) and included those components that were significant-

ly associated with the disease severity markers viz degree of bronchial dilatation and num-

ber of broncho-pulmonary segments with emphysema. The score for BRICS ranged from 0

to 5; 1 indicated mild disease, 2 – 3 indicated moderate disease and 4 – 5 indicated severe

disease. The ROC curve values in the derivation cohort were 0.79 for per cent predicted

FEV1, 0.71 for sputum purulence and 0.75 for hospital admissions per year. Similar ROC

curve values were obtained in the validation cohort of 302 patients in six centres.

The higher levels of neutrophil elastase activity in the group with emphysema on CT scan

suggested that elastase may be the cause of emphysema in this group. There was a strong

correlation between the severity of the BRICS and the severity of the BSI and FACED score

(p<0.001 for both scores). However neither the BSI or FACED scores were significantly

correlated with percent predicted FEV1, sputum purulence or hospital admissions for bron-

chiectasis exacerbations.

The BRICS is a simple, robust scoring system based on CT features alone, that correlates

significantly with important clinical parameters and predicts disease severity in patients with

idiopathic and post-infective bronchiectasis.

The BRICS (Bronchiectasis Radiologically Indexed CT Score). A multicentre study score for use in idiopathic and post-infective

bronchiectasis.



Disclaimer: This publication is not intended as a replacement for regular medical education. The comments are an interpretation of the published study and reflect the opinion of the writer rather than those of the research group or scientific journal. It is suggested readers review the full trial data before forming a final conclusion on its merits. Privacy Policy: The APSR Secretariat will record your email details on a secure database and will not release it to anyone without your prior approval. The APSR and you have the right to inspect, update or delete your details at any time.

Asian Pacific Society of Respirology

APSR Respiratory Updates is an initiative of the APSR Education Committee

Articles selected and commented on by Professor John Kolbe, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland City Hospital, Auckland, New Zealand

Editor in chief: Dr David CL Lam, Department of Medicine, University of Hong Kong, Hong Kong, China

Compiled by Dr Christel Norman, Respirology Editorial Office, Perth, Australia

https://www.apsr2018.com/MYAPSR2018

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